Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAB PARTICLE AGGLUTINATION

Facility

$68.00

Service Code	CPT 86403
Hospital Charge Code	4086403
Hospital Revenue Code	302
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

LAB PARVOVIRUS B19 IGG

Facility

$92.00

Service Code	CPT 86747
Hospital Charge Code	4086747
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

LAB PARVOVIRUS B19 IGG

Facility

$92.00

Service Code	CPT 86747
Hospital Charge Code	4086747
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

LAB PARVOVIRUS B19 IGM

Facility

$92.00

Service Code	CPT 86747
Hospital Charge Code	4086748
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

LAB PARVOVIRUS B19 IGM

Facility

$92.00

Service Code	CPT 86747
Hospital Charge Code	4086748
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

LAB PERIPHERAL BOLLD SMEAR

Facility

$183.00

Service Code	CPT 88323
Hospital Charge Code	4088323
Hospital Revenue Code	300
Min. Negotiated Rate	$128.10
Max. Negotiated Rate	$183.00
Rate for Payer: Aetna Commercial	$173.85
Rate for Payer: Aetna Medicare	$164.70
Rate for Payer: BCBS MT CHIP	$164.70
Rate for Payer: BCBS MT Closed Plan Network	$173.85
Rate for Payer: BCBS MT HealthLink	$164.70
Rate for Payer: BCBS MT Medicare	$164.70
Rate for Payer: BCBS MT POS	$173.85
Rate for Payer: BCBS MT Traditional	$183.00
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cigna Commercial	$173.85
Rate for Payer: Cigna Medicare	$164.70
Rate for Payer: Medicaid All Medicaid	$168.36
Rate for Payer: Medicare All Medicare	$128.10
Rate for Payer: Monida Allegiance	$173.85
Rate for Payer: Monida First Choice Health	$177.51
Rate for Payer: Monida Montana Health Co-op	$173.85
Rate for Payer: Monida PacificSource	$173.85

LAB PERIPHERAL BOLLD SMEAR

Facility

$183.00

Service Code	CPT 88323
Hospital Charge Code	4088323
Hospital Revenue Code	300
Min. Negotiated Rate	$128.10
Max. Negotiated Rate	$183.00
Rate for Payer: Aetna Commercial	$173.85
Rate for Payer: Aetna Medicare	$164.70
Rate for Payer: BCBS MT CHIP	$164.70
Rate for Payer: BCBS MT Closed Plan Network	$173.85
Rate for Payer: BCBS MT HealthLink	$164.70
Rate for Payer: BCBS MT Medicare	$164.70
Rate for Payer: BCBS MT POS	$173.85
Rate for Payer: BCBS MT Traditional	$183.00
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cigna Commercial	$173.85
Rate for Payer: Cigna Medicare	$164.70
Rate for Payer: Medicaid All Medicaid	$168.36
Rate for Payer: Medicare All Medicare	$128.10
Rate for Payer: Monida Allegiance	$173.85
Rate for Payer: Monida First Choice Health	$177.51
Rate for Payer: Monida Montana Health Co-op	$173.85
Rate for Payer: Monida PacificSource	$173.85

LAB PHOSPHATE

Facility

$58.00

Service Code	CPT 84105
Hospital Charge Code	4084105
Hospital Revenue Code	300
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

LAB PHOSPHATE

Facility

$58.00

Service Code	CPT 84105
Hospital Charge Code	4084105
Hospital Revenue Code	300
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

LAB: PICC LINE DRAW

Facility

$124.00

Service Code	CPT 36592
Hospital Charge Code	1026592
Hospital Revenue Code	450
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

LAB: PICC LINE DRAW

Facility

$124.00

Service Code	CPT 36592
Hospital Charge Code	1026592
Hospital Revenue Code	450
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

LAB PINWORM EXAM

Facility

$47.00

Service Code	CPT 87172
Hospital Charge Code	4087172
Hospital Revenue Code	300
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

LAB PINWORM EXAM

Facility

$47.00

Service Code	CPT 87172
Hospital Charge Code	4087172
Hospital Revenue Code	300
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

LAB PKU

Facility

$51.00

Service Code	CPT 84030
Hospital Charge Code	4084030
Hospital Revenue Code	301
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$48.45
Rate for Payer: Aetna Medicare	$45.90
Rate for Payer: BCBS MT CHIP	$45.90
Rate for Payer: BCBS MT Closed Plan Network	$48.45
Rate for Payer: BCBS MT HealthLink	$45.90
Rate for Payer: BCBS MT Medicare	$45.90
Rate for Payer: BCBS MT POS	$48.45
Rate for Payer: BCBS MT Traditional	$51.00
Rate for Payer: Cash Price	$45.90
Rate for Payer: Cigna Commercial	$48.45
Rate for Payer: Cigna Medicare	$45.90
Rate for Payer: Medicaid All Medicaid	$46.92
Rate for Payer: Medicare All Medicare	$35.70
Rate for Payer: Monida Allegiance	$48.45
Rate for Payer: Monida First Choice Health	$49.47
Rate for Payer: Monida Montana Health Co-op	$48.45
Rate for Payer: Monida PacificSource	$48.45

LAB PKU

Facility

$51.00

Service Code	CPT 84030
Hospital Charge Code	4084030
Hospital Revenue Code	301
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$48.45
Rate for Payer: Aetna Medicare	$45.90
Rate for Payer: BCBS MT CHIP	$45.90
Rate for Payer: BCBS MT Closed Plan Network	$48.45
Rate for Payer: BCBS MT HealthLink	$45.90
Rate for Payer: BCBS MT Medicare	$45.90
Rate for Payer: BCBS MT POS	$48.45
Rate for Payer: BCBS MT Traditional	$51.00
Rate for Payer: Cash Price	$45.90
Rate for Payer: Cigna Commercial	$48.45
Rate for Payer: Cigna Medicare	$45.90
Rate for Payer: Medicaid All Medicaid	$46.92
Rate for Payer: Medicare All Medicare	$35.70
Rate for Payer: Monida Allegiance	$48.45
Rate for Payer: Monida First Choice Health	$49.47
Rate for Payer: Monida Montana Health Co-op	$48.45
Rate for Payer: Monida PacificSource	$48.45

LAB PLATELET FUNCTION

Facility

$130.00

Service Code	CPT 85576
Hospital Charge Code	4085576
Hospital Revenue Code	305
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

LAB PLATELET FUNCTION

Facility

$130.00

Service Code	CPT 85576
Hospital Charge Code	4085576
Hospital Revenue Code	305
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

LAB PORPHYRINS URINE QUANT & FRACTIONATN

Facility

$130.00

Service Code	CPT 84120
Hospital Charge Code	4084120
Hospital Revenue Code	300
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

LAB PORPHYRINS URINE QUANT & FRACTIONATN

Facility

$130.00

Service Code	CPT 84120
Hospital Charge Code	4084120
Hospital Revenue Code	300
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

LAB PRENATAL PROFILE

Facility

$182.00

Service Code	CPT 80055
Hospital Charge Code	4080055
Hospital Revenue Code	300
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

LAB PRENATAL PROFILE

Facility

$182.00

Service Code	CPT 80055
Hospital Charge Code	4080055
Hospital Revenue Code	300
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

LAB PRIMIDONE

Facility

$167.00

Service Code	CPT 80188
Hospital Charge Code	4080188
Hospital Revenue Code	300
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

LAB PRIMIDONE

Facility

$167.00

Service Code	CPT 80188
Hospital Charge Code	4080188
Hospital Revenue Code	300
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

LAB PRO INSULIN

Facility

$189.00

Service Code	CPT 84206
Hospital Charge Code	4084206
Hospital Revenue Code	301
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: BCBS MT CHIP	$170.10
Rate for Payer: BCBS MT Closed Plan Network	$179.55
Rate for Payer: BCBS MT HealthLink	$170.10
Rate for Payer: BCBS MT Medicare	$170.10
Rate for Payer: BCBS MT POS	$179.55
Rate for Payer: BCBS MT Traditional	$189.00
Rate for Payer: Cash Price	$170.10
Rate for Payer: Cigna Commercial	$179.55
Rate for Payer: Cigna Medicare	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

LAB PRO INSULIN

Facility

$189.00

Service Code	CPT 84206
Hospital Charge Code	4084206
Hospital Revenue Code	301
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: BCBS MT CHIP	$170.10
Rate for Payer: BCBS MT Closed Plan Network	$179.55
Rate for Payer: BCBS MT HealthLink	$170.10
Rate for Payer: BCBS MT Medicare	$170.10
Rate for Payer: BCBS MT POS	$179.55
Rate for Payer: BCBS MT Traditional	$189.00
Rate for Payer: Cash Price	$170.10
Rate for Payer: Cigna Commercial	$179.55
Rate for Payer: Cigna Medicare	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

Know your out-of-pocket cost for care.

All Charges